From what you wrote, I have the sense that this has been a gradual increase in respiratory effort with activity. Nobody likes to go to the ER unless they have to. To help you decide whether this is something to go to the ER or whether this is something that can be addressed more routinely, answer the following: 1. Have you gained 5 or more lbs over the last week? 2. Are you more short of breath with laying flat - has this worsened over the last week? 3. Are your swollen - usually at the ankles? 4. Has there been a sudden increase in your shortness of breath over the last week? If you answered yes to at least two of the above questions, go to the ER, you are in congestive failure and need to be diuresed. (get the extra fluid out of your body) If you answered yes to one of the questions - if you feel like you are in respiratory distress, proceed. If you answered yes to none of the above questions, then you are probably fine to wait and be seen more routinely. Of course, if things change while waiting - proceed. From what you ve written, I do have some suggestions to consider regarding your therapy - which was your original question. 1. Add Spironolcatone. (improves remodeling) 2. Add Lasix (reduces congestive symptoms - primarily a comfort step) 3. Add an ARB (example Losartan) in addition to your ACE inhibitor (Rampiril) medication. (improves remodeling) 4. Increase the dose of the Carvediol up to 25mg two times per day. (improves remodeling) 5. Add Digoxin. (improves contractility) 6. Consider cardiac resynchronization therapy via a biventricular pacemaker which can be useful with certain patients. You may also qualify for consideration of an ICD (defibrillator) per the MADIT 2 criteria. 7. Evaluate and ideally manage any other processes that might be effecting your cardiac function - sleep apnea, valve function (especially mitral valve), diabetes, hypertension are all examples that can negatively effect your condition. Discuss these measures with your physician. They all have medical literature behind them endorsing their use. I of course would not do everything at once, but you have some options about where to go. If your physician discounts additional changes then I might request a referral to speak with a specialist. I hope this is helpful. Good luck.